MCO designs road map for depression care
Evidence-based guidelines gain provider support
Roughly 10% of patients in the primary care setting present with some level of depression. Even more alarming, dropout rates for treatment compliance run as high as 30% in the first month, according to the American Psychiatric Association in Washington, DC, making this an obvious mental health diagnosis for systems to target for a disease management initiative.
"Nationally, diagnosing and treating depression in primary care settings is a challenge," says Marvin Rosenberg, ACSW, BCD, Depression Roadmap team coordinator with the clinical planning and improvement division of Group Health Cooperative of Puget Sound in Seattle. "Depression is often an illusive disorder which masquerades in the form of physical problems like back pain or sleep problems. Patients are reluctant to accept a diagnosis of depression, especially when it is manifested in physical symptoms. This poses a challenge to providers to openly discuss depression with patients."
Where do patients go with their depression?
A randomized controlled study of Group Health patients conducted by independent researchers in the Seattle area found that 70% of depression management occurred in the primary care setting. This means that 30% of all patients who present with depression either seek help in specialty clinics or receive no help at all, notes Rosenberg. The challenge for the managed care organization (MCO) was to provide consistent and appropriate diagnosis and treatment of depression for that 70% of depressed patients who sought treatment in its primary care clinics.
One early step was to organize small focus groups of Group Health members who had been treated for depression to identify current practices within Group Health. "We asked members to describe their experiences of diagnosis and treatment of depression and found that they had widely different experiences," says Rosenberg. In fact, it quickly became clear that no two members followed the same course of treatment.
These are just a few of the dozens of anecdotes members shared in focus groups:
• A patient went to her primary care physician, who prescribed an antidepressant, which she discontinued after a short time without consulting her physician because of side effects. Eight months later, still experiencing symptoms of depression, the patient went to a behavioral health specialty center and was successfully treated.
• A patient went to his primary care physician who had known him and his family for years. The physician prescribed an antidepressant. The patient took the prescription as directed, followed up regularly with the physician, and improved.
• A patient saw a master’s degree-prepared therapist, began cognitive behavioral therapy, and discontinued treatment after four sessions with no marked improvement in depression symptoms.
"We learned quickly from our focus groups that there were unintended variations in treatment plans for behavioral health diagnoses, depending on where in the system patients accessed care," notes Rosenberg. "We realized that we were going to have to implement a systematic behavioral health initiative that focused on consistent mechanisms for diagnosing, monitoring, and patient education."
Group Health has developed many successful clinical guidelines for chronic conditions such as diabetes and heart disease. The formula the MCO used for those programs was applied to the Depression Roadmap, an algorithm that gives providers clear clinical decision points for treating depression — including when prescriptions for antidepressants are appropriate — and a schedule for follow-up and reassessment. An evidence review team consisting of psychiatrists, psychologists, social workers, pharmacists, primary care physicians, a clinical epidemiologist, and staff from the provider education and guideline development departments was pulled together to develop the new guideline. The team met two hours a week for more than a year creating evidence tables from major depression studies.
Developing evidence-based algorithms rather than relying on guidelines based solely on expert opinion goes a long way toward reducing physician resistance to any disease management effort, Rosenberg adds. "Health care providers are scientifically trained and carry thousands of algorithms in their heads for the diagnosis and treatment of disease. They are highly motivated to provide the best possible care. Evidence-based guidelines, care algorithms, and tools to assist with diagnosis and symptom monitoring help this process."
He cautions that clinical guidelines are not intended to substitute for clinical experience and sound medical judgment but rather to aid the provider’s decision-making process by incorporating the best available scientific evidence. The Depression Roadmap organizes and structures clinical information in the same manner practitioners are trained to think about and treat physical disorders, notes Rosenberg. For example, the literature review revealed that targeting major depression was likely to produce the best outcomes.
"From the research, it’s clear that patients suffering from moderate to severe forms of major depression are most likely to achieve the best treatment outcome when treated with a guideline-based approach which includes an accurate diagnosis, consistent follow-up, and patient education. Evidence that patients suffering from minor depression or situational adjustment disorders get better with a similar approach is less clear."
Six steps to success
Group Health’s Depression Roadmap has been in place for more than a year and began systemwide implementation in 1998. The program includes:
• Depression diagnostic tool/symptom severity scale. To facilitate an open dialog between providers and patients, Group Health developed a simple two-page, self-administered diagnostic tool based on the DSM IV checklist for depression and a five-question depression severity scale for use in the primary care setting, notes Rosenberg.
"The depression scale can be explained by office staff and completed by the patient. The tools help confirm the diagnosis and also help track the patient’s progress when used to reassess the patient at regular intervals, says Rosenberg. "Our treatment goals call for at least a 50% reduction in the severity scale score or significant improvement based on the provider’s clinical judgment within four to eight weeks of initial treatment."
Primary care physicians have reported that the diagnostic tools are one of the best aids they have ever used as part of a quality improvement initiative, notes Rosenberg. "Providers say the diagnostic tools give them a common language to talk about depression with their patients. The patient reads the form and completes it. The provider can then say, Because you answered that question in this way, it means this.’ The tools provide a ready form of discussion for what is often a very difficult thing for patients to accept. People are very reluctant to accept they are depressed. We simply haven’t made significant gains culturally to make a behavioral health diagnosis acceptable to most patients."
Providers often have a mental algorithm when they assess their patients, he notes. "If I am a provider, I might ask a patient a series of questions in an informal interview. I have a checklist in my mind that the patient can’t see. The patient doesn’t know I have an algorithm for diagnosis in my head. It has less meaning for the patient than a tool filled out by the patient that the provider can actually show the patient and to discuss symptoms and treatment."
• Required training sessions. Group Health held sessions to educate clinicians on the proper use of the depression diagnostic tool and severity scale. "It’s the first time we’ve ever held a non-optional continuing education effort around population management that included providers from all disciplines," says Rosenberg. "We made sure that physicians, nurses, and therapists throughout the system — including primary care and behavioral health specialty clinics — knew how to administer and score these tools. We also familiarized everyone with the algorithm. It took us six weeks to complete all the initial training. If someone absolutely couldn’t attend a session, we provided them with a training video."
Now, Rosenberg has hit the road to revisit each clinic and provide educational updates and gather feedback from providers about the tools and the guidelines.
• Depression algorithm with shorthand cards in each examination room. "We provided shorthand versions of the algorithm in each exam room. If a clinician is in the room with a patient and can’t remember what that next step should be in either diagnosis or treatment, they can refer to the card," notes Rosenberg. "The algorithms are also on our computer system; but this way, the provider doesn’t have to leave the exam room to find the information."
In addition to the algorithm with all the clinical decision points, the exam room cards include scoring scales for the diagnostic tool and the severity scale, and a list of all the antidepressant medications with dosages and side-effect profiles. "It’s a quick reference tool to help clinicians. Providers can’t possibly remember all this information. Group Health currently has more than 30 of these clinical guidelines," he explains.
• Full-service population registry. "Patients diagnosed with depression are automatically entered into the registry and placed into one of two categories: medication track if they are given a prescription for an antidepressant, or active support and watchful waiting if they either have a diagnosis of mild depression or are reluctant to initiate treatment."
Once patients are placed on either of these tracks, the registry clocking system automatically sends providers clinical reminders and decision support tips that track the schedule for follow-up visits and reassessment.
The medication treatment track has three treatment phases — acute, continuation, and maintenance — each with its own timed reminders. Any patient who has received a prescription for an antidepressant and a diagnosis of depression is placed on the track. "It’s important that there is a diagnosis of depression. Antidepressants are sometimes prescribed for other conditions," notes Rosenberg.
The reminders are sent via the clinical work stations all providers in the Group Health system have in their clinics. "The registry allows the entire delivery system to have access to patient information regardless of the delivery setting," says Rosenberg. "For example, a patient comes to Clinic A and sees a provider and is diagnosed with depression. The patient then comes back for an unrelated complaint, such as a sinus infection and the patient’s regular provider is on vacation. The treating provider could look on the registry to identify any necessary assessment or treatment needs. Any provider in the system, even if the patient goes to another clinic other than the clinic where the initial treating provider practices, has access to the registry and can ask the right questions and do the right procedure and the patient doesn’t fall through the cracks."
It’s often assumed that once patients start antidepressants, their symptoms will improve, but that’s not always the case, adds Rosenberg. "The guidelines call for reassessment using the severity scale within the first four to eight weeks of treatment."
Improving follow-up with patients
For patients with mild depression who are placed in the "active support and watchful waiting" track, the registry sends reminders to have them reassessed. "It’s a way of capturing a whole population of patients who are often lost to treatment in primary care. Most primary care structures are built to provide acute care. But patients with mild depression may be getting worse and may require additional care down the road."
Early on, Group Health provided clinicians with bright yellow printed prescription pads that were placed in exam rooms in one of its primary care clinics. The pads referenced the diagnostic tools and listed the drugs used to treat depression and the recommended dosages. "Our initial goal in introducing the prescription pads was to provide a visual reminder to raise clinician consciousness about the recommended treatments for depression," Rosenberg says. "If they had liked them, we would have continued them, but providers told us they didn’t like hunting around for the right prescription pad. It was too cumbersome to carry or locate multiple pads."
• Follow-up to encourage compliance. Each primary care team is given the authority to assign patient follow-up in the most appropriate way for its practice and patient population. "Follow-up visits don’t always require a physician," notes Rosenberg. "If a patient is progressing, is not having medication side effects, and is not suicidal, there’s no need for the physician to intervene for routine follow-up. It’s when the patient indicates a problem with treatment that the patient must be triaged to the appropriate discipline or the specialty service."
Group Health allows each team to delegate follow-up calls. "If a patient has been severely depressed and suicidal, the physician or behavioral health specialist may choose to handle the follow-up. If the patient has a good relationship with a nurse on the primary care team, the nurse may do the follow-up for that patient. It’s about finding the right person to make the right contact, with the physician overseeing the process."
The Depression Roadmap team found that the literature indicates that roughly 30% of patients discontinue antidepressant medications after one month, and 44% discontinue after three months, says Rosenberg. "That’s a lot of patients falling out of treatment. It seems the first month is very important. It seems reasonable that encouraging patients to continue their medication with two to three contacts in the first month will reduce that discontinuation rate."
• Patient education. This year Group Health introduced a patient education pamphlet, written in-house, that provides basic information on the spiral of depression, available treatments for depression, and answers to the most commonly asked questions about the diagnosis and treatment of depression. In addition, the pamphlet includes a self-care section that focuses on behavioral activation.
"Any clinician who treats depression knows that refocusing patients on pleasurable events, encouraging them to make time in their lives for activities they enjoy, and emphasizing the importance of spending time with supportive people, helps balance distorted or negative thoughts," says Rosenberg. "We also emphasize the importance of staying physically active and learning relaxation and stress reduction techniques."
Education materials
The Group Health Depression Roadmap team reviewed commercially available education materials on depression before writing its own patient education pamphlet.
"We found that although many were very good, they were missing one piece or another," Rosenberg says. "They weren’t integrated with the algorithm we use to systematically treat depression. We wanted a piece that fit with our organizational commitment to doing this work and linked all the elements of our Depression Roadmap together."
Group Health has been measuring the success of its Depression Roadmap using chart reviews to determine the effectiveness of various elements of its depression guidelines, including follow-up, and encouraging treatment compliance and plans to publish the results soon. "Our initial findings and feedback from providers, indicates that the diagnostic tools are particularly useful," notes Rosenberg. "As we’ve toured our delivery system and visited clinics, our findings have been very positive overall."
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